Provider Demographics
NPI:1215141973
Name:BROOKE GROVE FOUNDATION, INC.
Entity type:Organization
Organization Name:BROOKE GROVE FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR. OF CORP. FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:SPILLANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-388-7204
Mailing Address - Street 1:18100 SLADE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20860-1313
Mailing Address - Country:US
Mailing Address - Phone:301-924-2811
Mailing Address - Fax:301-924-1200
Practice Address - Street 1:154 N ARTIZAN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795-1104
Practice Address - Country:US
Practice Address - Phone:301-924-2811
Practice Address - Fax:301-924-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21-014314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21760760000Medicaid
MD1215141973Medicare NSC
21-5198Medicare ID - Type Unspecified